L5/S1 Herniation Question

Looking for advices and new ideas to research in the treatment of my disc issue. I am a 28 year old female with no children (but hope to have them some day!) I was injured on the job. The final back insult came on 12/27. Following a "pull" I felt, I had several days of severe sciatica that led to an ER visit.

Today, 23 days post-injury. I am completely pain-free and not on any sort of pain medication (including NSAIDs.) However, I have a slight limp that seems to be improving due to nerve impingement on the S1 nerve root. In addition, I have decreased sensation around the back of my calf and on my outer foot and toes due to the nerve impingement as well.

These symptoms seem to be improving with time, ever so slightly.

The MRI states there is a large herniation at L5/S1 that is off to the left and that extends as much as 2CM below the disc space level - the report goes on to say that this MAY represent a free fragment.

Despite research I have been unable to fully understand what this means. My PCP pushed me up for surgical consults and told me not to begin the PT that I was scheduled to begin until the MRI had been viewed by a NS or Ortho.

My question is this: Has anyone been in this situation before? What are the implications of this "free fragment" if it exists? Does that mean my disc has ruptured?

Also, from a surgical perspective - did anyone have surgery for this?

My symptoms seem to have improved slightly even without PT over the past 23 days and I have absolutely zero pain - just slight weakness and numbness which, from what I understand, may not go away even with the surgery. I tend to think that by virtue of my symptoms having improved that the pressure on the nerve root has subsided a bit as well already. In addition, I have a hard time justifying surgery when I have zero pain - especially since surgery and scar tissue growth could end up causing more pain.

Lastly, and this question is because some of the stories on this board horrify my, how much does this surgery de-stabilize the spine? My father had his disc removed in the 70's and he's A-Ok to this day with no complaints and he's not particularly in shape either. I'm trying to look out for my spine now, and in the future.

Welcome to the board. You ask many good questions. I will try to answer them. The main thing that distinguishes your issue from the typical herniation is the potential of the disc fragment...but I don't believe that changes how you would approach treatment or even your thinking on whether you should have surgery.

Here in the US we operate on herniated discs far more frequently than any other country. About 18 years ago, my husband ruptured the disc at L5-S1. It was less common then to do surgery, and he was advised by two spine surgeons to wait and give it a chance to heal. Even though it was extremely painful, he didn't have any of the symptoms that indicate surgery is immediately necessary -- symptoms of cauda equina like loss of bladder or bowel control, or immediate loss of muscle strength. Like you, he began to improve...and was able to heal without any surgical intervention. He has not had any major problems since and still leads an active lifestyle and still runs.

The reason most people opt for surgery is due to a surgeon's advice, pain, and the unwillingness to wait a bit to see if things get better through conservative treatment.

I certainly don't want to contradict what your PCP told you, but I don't understand his thinking on waiting on PT. Pt is usually what makes the patient stronger, provides more stability and helps to move the nerve away from whatever is compressing or irritating it. Also, the usual next treatment would be an epidural steroid injection, which is intended to shrink the tissue and whatever inflammation there may be so that the patient is able to begin working with a physical therapist to accomplish the goals mentioned in the preceeding sentence.

The floating disc fragment is a problem that can arise even after surgery. When a disc breaks through the outer wall, it can ooze out or pieces can break off and are then referred to as a disc fragment. Sometimes in a discectomy, the doctor thinks he has removed what he intended to, but occasionally a piece will not be noticed at the time, or is otherwise left behind. This fragment does not necessarily cause an issue unless it nestles up against a nerve, in which case it becomes a source of irritation to the nerve or it can take up space that is needed by the nerve to move freely, in which case it can cause some nerve compression.

The disc is not always removed when a discectomy is performed. Often the surgeon will just "shave off" the portion that is bulging. Then the disc eventually scabs over and toughens back up. If the surgeon removes the entire disc, then something has to go into that space to keep the vertebrae from rubbing bone on bone. This is when you get into a fusion surgery or artificial disc replacement. It could cause instability if the disc were completely removed, depending on what other components are removed during the surgery, (such as the lamina, for example).

They used to tell people to wait for six months before performing surgery...to try all conservative measures first. In your case, since you do not seem to have any major nerve compression, I think you would be smart to wait and see how much your body can heal naturally.

There tend to be a lot of "worse case scenarios" on forums such as this...but it does remind us that there is always a risk involved with surgery, even when using the "best" surgeon in the "best" hospital, etc. Just ask the people on here who ended up with drop foot after what was supposed to be a routine surgery....

As you stated you are young so it would be nice to maintain your spinal integrity as long as possible. Obviously you don't want to end up with permanent nerve damage from waiting "too" long...(since that varies from case to case, no one really knows how long is "too" long....), but in your case, it sounds like you can afford to wait at least for a month or two.

One thing to always keep in mind is that back surgery is not like most other surgeries in that it will NOT restore you to the way you were prior to onset of injury or pain. Once the spine is opened and operated on, it will never be the same. The structural integrity is altered, and it will never be like it was when you were younger.

Sorry this is so long. I probably didn't even answer all your questions, so please ask more, if you have them.

I should add that I do think it is wise to follow through with a fellowship-trained orthopedic spine or neuro surgeon. Because back injuries are so common, family physicians, internists and PCPs receive some training in problems of the neck and back, but a patient can also waste a lot of valuable time dealing with one who inadvertently misleads the patient.(I speak from personal experience!)

Also with a lower lumbar injury, it is a good idea to have someone lined up in the event that your injury suddenly gets worse and you require surgery (highly unlikely in your case). If you already have your name in the spine specialist's computer, you will be able to get an appointment faster and if surgery were needed on an emergency basis, you wouldn't have to take pot-luck in the E.R.

Also, I forget to mention that disc fragments can be healed without surgery. They can be reabsorbed by the body.
One study concludes "... a patient with extruded disc fragment as seen on MRI can be treated conservatively, provided he is improving and does not have significant neurological deficit."

Thanks so much for the reply. I'm holding out hope that the surgeons agree with conservative treatment for this problem...I feel like I have more to lose from surgery than to gain, specifically from a pain standpoint.

Additionally, I have been reading information on how larger herniations tend to be the ones that actually seem to have an easier time "shrinking." I certainly hope that is the case.

I do recognize that my spine will be forever altered, unfortunately. Luckily, I have my father as a great example that life can, and does, go on quite normally for many people (which is a perspective I think I find less of on here - clearly the people who "got better" don't frequent this place anymore!)

I read something that said "to make your back better, you really have to work at it" and that is true, and absolutely what I am prepared to do...I will always prefer that someone else picks up something off of the ground instead of me, I will always work out with a trainer from this point forward (once allowed!) and exercise more, etc.

I'm really hoping surgery is not the answer. I am someone who likes to think in "worst case scenarios" and I will not accept a chronic history of back problems, fusions, etc. I am even planning on changing my career to get out of bedside nursing as I'm refusing to "tempt fate" and end up in this situation again.

I would be really surprised if a spine specialist wanted you to have surgery. Insurance carriers won't even approve it until the patient has tried a variety of conservative measures, unless there are cauda equina issues or drastic muscle weakness.

It is technically possible for a person's back to be stronger post surgery, but obviously doesn't happen very often! The ideal situation is for you to heal without having surgery, and then to strengthen the back and core through exercise, make any needed lifestyle changes, use good body mechanics and maintain good posture, etc.

I think the "lucky" back patients are the ones who have a brief flirtation with the possibility of needing surgery, but are able to heal without it. Some of them then begin to take good care of their spines from that point forward!

On the other hand lots of people recover from a herniation and then go right back to all those bad habits that got them into that predicament to begin with -- lack of exercise, poor diet, excessive weight, slouching in front of the TV or computer, etc.

With all your knowledge and determination, I feel confidant you'll be able to heal this herniation with conservative treatment.